Release of Information

I consent to the release by Z-Roc Dermatology, LLC (“Z-Roc Dermatology”) of health records and information about me, to the extent permitted by law, to the following individuals and entities:

• To a health care provider being advised of or consulted in connection with my treatment or care.
• To a health plan, insurer, third-party payor, third party administrator or other organization providing me with health benefits, for the purposes of claims payment and benefit determinations, fraud investigations, or quality of care studies or reviews.
• To a person or organization in connection with Z-Roc Dermatology’s health care operations. These operations may include, but are not limited to, interdisciplinary care conferences, quality improvement activities, performance evaluations, business management, and other related activities.
• To a person or organization providing services in connection with Z-Roc Dermatology’s patient health record portal or the person or organization hosting or providing the portal service.
• To a health information exchange where my information may be shared with and accessed by other health care providers and health care related entities for purposes of treatment, payment, and the health care operations of the participating organizations.
• To the individuals that I included on my Consent to Communications from Z-Roc Dermatology form.

Record Locator and Patient Information Services. I consent to Z-Roc Dermatology searching for, accessing, and/or receiving health information about me and the location of my health records through a record locator service and/or patient information service.

Revocation. I understand and agree that this consent and authorization is valid until I revoke it, which I may do at any time by giving written notice to Z-Roc Dermatology. I further understand and agree that revocation will not apply to information that has already been disclosed pursuant to this Consent and Authorization Form.

Payment Responsibility and Authorization

Payment Responsibility

I agree that I am financially responsible and shall pay for all services furnished to me by Z-ROC Dermatology and any providers performing services on my behalf at the request of Z-Roc Dermatology including, but not limited to, charges that are not paid in full by my insurance, government program benefits or other third-party payors (each a “Third-Party Payor” and collectively, “Third-Party Payors”). I shall make these payments upon receipt of a statement. I understand and agree that Z-Roc Dermatology is not responsible for collecting payments from Third-Party Payors or negotiating disputed settlements on my behalf. I agree to pay or reimburse Z-Roc Dermatology for all costs it may incur in collecting amounts owed to it for the services provided to me, including, but not limited to, attorneys’ fees and collection agency fees.

Payment Authorization

I shall inform Z-Roc Dermatology of all Third-Party Payors through which I may have benefits covering the services provided to me by or on behalf of Z-Roc Dermatology. I authorize Z-Roc Dermatology to directly bill my Third-Party Payors for such services but acknowledge that Z-Roc Dermatology is not obligated to submit claims to a Third-Party Payor(s) on my behalf unless required by law or by its contract with a Third-Party Payor. I also authorize any Third-Party Payor through which I may have benefits to make payment directly to Z-Roc Dermatology for such services, and to release any medical information about me needed to determine the benefits payable for such services. If I have a Medicare Supplement Insurance (Medigap) policy, I request that payment of authorized Medigap benefits be made to Z-Roc Dermatology directly on my behalf by my Medigap insurer.

Payment of Medicare Benefits to Z-Roc Dermatology

I request payment of authorized Medicare benefits to be made either to me on my behalf to Z-Roc Dermatology for services furnished to me by Z-Roc Dermatology. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

Referrals and Prior Authorizations

I understand and agree that it is my responsibility to know and abide by the terms of my Third-Party Payor coverage, including referral or authorization requirements and other types of benefit limitation. I understand that I am responsible for obtaining any required referrals for specialized care before making appointments. I agree to obtain a required authorization for services or to provide all information needed by Z-Roc Dermatology to obtain a required authorization in advance of my visit. If my Third-Party Payor refuses to cover the services I receive, based on the lack of a required referral or authorization or otherwise, I understand I am financially responsible and agree that I will pay for the services provided by Z-Roc Dermatology, except to the extent such obligation is limited by applicable law or contractual obligations of Z-Roc Dermatology applicable to payment for those services.

Full Body Skin Cancer Screenings

I understand and agree that routine full body skin cancer screenings are not covered in full as a preventative service under most health plans, including Medicare. If my Third-Party Payor requires the payment of a copay for these screenings (e.g., as a specialist visit), I agree to pay this copay at the time of service. I further understand that Z-Roc Dermatology will send me an invoice for any coinsurance or deductible balances due, and I agree to timely pay the amount specified on this invoice.

Notice of Privacy Practices

Confidentiality

It is the policy of Z-Roc Dermatology to protect the privacy and confidentiality of my health information in compliance with applicable law.

Notice of Privacy Practices

Z-Roc Dermatology’s Notice of Privacy Practices explains how Z-Roc Dermatology may use and disclose my health information. It also explains my rights regarding this kind of information. Z-Roc Dermatology may revise its Notice of Privacy Practices at any time and will provide me with a copy of the revised Notice of Privacy Practices at my request. Z-Roc Dermatology’s Notice of Privacy Practices is available at each of its clinics and on its website (www.zrocderm.com).

Acknowledgment of Receipt. I acknowledge that I have received Z-Roc Dermatology’s Notice of Privacy Practices.

Consent for Treatment

I understand that I have the right to be informed of the nature and purpose of all services provided to me at Z-Roc Dermatology, as well as alternatives, risks, consequences, or complications of such services. I hereby authorize and consent to the examination, diagnosis, procedures, and treatments which my practitioner and I agree are appropriate. I understand that no guarantee has been made as to the results of the care, treatment, and/or medications given to me. This consent shall remain in effect until I choose to revoke it in writing.

Public Comments

Before publicly making or posting any negative or critical comments about Z-Roc Dermatology (e.g., on social media, the internet (including review sites), etc.), I agree to notify Z-Roc Dermatology of my concerns in writing and wait thirty (30) days before publicly making or posting any such comments, thus allowing Z-Roc Dermatology the opportunity to address my concerns.

Late Arrivals

If you are more than 15 minutes late for your appointment, we may reschedule your appointment. We understand that patients sometimes experience unavoidable delays and will do our best to accommodate patients that arrive more than 15 minutes after their scheduled appointment. However, if we are unable to make this accommodation without negatively impacting other patients (e.g., by increasing their wait time), we will work with you to find a new day and time that works well for your schedule. We may decide to terminate our professional relationship with you if you have three or more late arrivals.

“No Show” Appointments

If you do not attend your scheduled appointment without giving us any prior notice, you may be charged a “no show” fee in the amount of $100.00 for cosmetic/surgical. We may decide to terminate our professional relationship with you if you have two or more “no show” appointments.

Late Cancellations

If you cancel an appointment less than 24 hours before the appointment, you may be charged a “no show” fee in the amount of $50.00. We may decide to terminate our professional relationship with you if you cancel two or more appointments with less than 24 hours’ notice.

Surgical Appointment Cancellations

Cancellation of a surgical appointment must be made at least 2–3 days in advance. This allows us ample time to offer the appointment slot to another patient in need. Failure to provide a minimum of 2–3 days’ notice for a cancellation of a surgical appointment may result in a “no show” fee in the amount of $100.00. This fee will be discussed with you at the time of cancellation and will depend on the specific circumstances.

Please read and be certain that you understand the information contained in this form. This form is a consent for the treatment described below, and contains a summary of the risks and benefits associated with the treatment. Before you receive the treatment, your provider will provide you with additional information about these risks and benefits and answer any questions that you may have about the treatment or related matters. If you have any questions or concerns at any time, please contact your provider.

General Consent to Treatment

My provider and I have discussed the treatment(s) and/or procedure(s) that have been deemed advisable, desirable, or necessary for diagnostic, therapeutic or investigational purposes for me or my minor child (collectively, “Treatment”), and I understand that such Treatment may involve the administration of drugs and anesthetics, the performance of a skin biopsy, the use of cryosurgery with liquid nitrogen and/or the injection of triamcinolone (cortisone). During these discussions, my provider told me about the Treatment’s intended purpose, risks and potential side effects, benefits, alternatives, and related information, and I had the opportunity to ask any questions that I may have had, all of which have been answered to my satisfaction. Based on this discussion and any related written materials that have been provided to me, I hereby consent to Z-Roc Dermatology, LLC (“Z-Roc Dermatology”) administration of the Treatment to me or to my minor child.

Consent to Skin Biopsy, Testing and Disposal

Biopsy

I understand that skin biopsies involve the removal of a piece of skin and may result in a permanent mark, scar or skin discoloration at the site of the biopsy, and that more than one biopsy may occur during a single visit. I consent to the performance of a skin biopsy(ies) when deemed necessary by my provider for the purposes of diagnosis or treatment. I understand that based on the results of the pathology, I may need to have additional tissue removed at a future office visit and that this will result in an additional charge.

Testing

I understand and agree that (1) any tissue sample obtained during the Treatment will undergo a dermatopathological analysis, which is conducted by specially trained providers in a laboratory setting, the results of which will assist in the development of a diagnosis and treatment plan; (2) such analysis may be conducted by a third party (i.e., an entity other than Z-Roc Dermatology); and (3) additional testing and/or a second opinion may be needed to obtain a definitive diagnosis and develop the most appropriate treatment plan. I further understand and agree that any such analysis will be billed to my insurance, and that I am personally responsible for paying any charges relating to such analysis that are not paid for by my insurance.

Disposal

I consent to the disposal of any tissue sample obtained by or on behalf of Z-Roc Dermatology when such samples are no longer needed or viable for testing.

Consent to Use of Liquid Nitrogen

Precancerous Lesions

I understand and consent to the destruction with liquid nitrogen of precancerous lesions, which are also known as actinic keratoses or solar keratoses, when deemed necessary or advisable by my provider to prevent the risk that these lesions will evolve into squamous cell carcinomas (a form of skin cancer). I understand that these lesions may require more than a single treatment.

Warts or Mollusca

I understand and consent to the destruction with liquid nitrogen of potentially contagious warts or mollusca, which are not cancerous and do not absolutely require treatment, when deemed necessary or advisable by my provider to prevent their spread. I further understand and agree that the destruction of a wart or mollusca may require multiple treatments.

Consent to Injection of Triamcinolone (Cortisone)

I understand and consent to the injection of triamcinolone (cortisone) when deemed necessary or advisable by my provider for the treatment of scars, cysts, acne and/or inflammatory conditions like psoriasis, atopic dermatitis and alopecia areata.

Risks and Possible Side Effects

The risks and possible side effects of the Treatment include, but are not limited to, the following:

• Permanent scarring
• Permanent discoloration of the skin at the site of treatment
• Atrophy (thinning or depression of the skin)
• Infection
• Bleeding
• Nerve damage resulting in temporary or permanent numbness or temporary or permanent loss of function of certain muscles (paralysis)
• Surgical site re-opening—including, but not limited to, movement, weight bearing, personal medical history, and wound location

The above list is not meant to be inclusive of all possible risks associated with the Treatment, as there are both known and unknown side effects and complications associated with any treatment or procedure.

ACKNOWLEDGEMENTS. By signing below, I acknowledge and agree to the statements listed above and the following:

• The nature and purpose of the Treatment has been explained to me, and I understand the information contained on this form in its entirety.
• I understand the risks associated with the Treatment and the alternative treatment methods have been explained to me. I know that I have the right to refuse the Treatment and, by signing below, I am consenting to the Treatment and accepting the associated risks and possible complications.
• I understand that medical attention may be required to address complications associated with the Treatment.
• I understand that the results of the Treatment are not guaranteed.
• I understand that any rescheduling of an appointment must be done at least 24 hours before the appointment and that, if I fail to timely cancel or reschedule an appointment, I may be billed for my missed appointment consistent with Z-Roc Dermatology’s Late Arrival, Cancellation and Return Policy.
• I understand and agree that all services rendered to me may be charged to me directly and that I am personally responsible for payment for the full cost of the Treatment.
• I certify that I am a competent adult of at least 18 years of age and that this consent form is signed freely and voluntarily. I hereby release any right to claim that the performance of any operation or procedure provided to me was not properly authorized.